Powermax USA

Product Malfunction

Customer Name
Address
City	State Zip
Country
E-Mail
Phone	Fax

Product Name
Product Type	Expire Date (on the side or bottom of batteries):
Product Size
Purchase Date:	Purchase Price
Purchased From	(fax/mail a copy of your receipt)

Malfunction?

Please describe the Malfunction
Date and Time of Malfunction
Location of Malfunction

Property Damage

Describe any property damage or device damage that was caused by the Malfunction
How did Malfunction cause this damage?
Has the damage been repaired?	Yes No
Estimated Cost of damage
(If applicable, please attach any repair estimates, receipts, and photographs of the damage.)

Personal Injury

Describe any injury caused by the Malfunction
Name / address of person(s) injured
How did Malfunction cause this injury?
Please describe any medical treatment given
Name / address of doctor or other medical treatment provider
Has the person recovered from the injury?	Yes No
List any medical insurance

Dry-Cell Batteries:

How many batteries in device?		Were all batteries replaced at the same time?	Yes No
Were batteries inserted correctly?	Yes No	Where were batteries stored prior to use?
Did you notice bulge, damage, or leak of battery prior to Malfunction?
Describe / Additional Comments

I Certify: All information is true and accurate (use email address as Signature)

Please return defective product(s), and any damaged device to:

Powermax USA (Attn: Malfunction Report)
11750 Jersey Blvd., Rancho Cucamonga, CA 91730

Powermax USA will investigate the reported Malfunction and will repair or replace at our option any device damaged due to a defective product.